Introduction

Esophagogastroduodenoscopy (EGD) has been performed as a population-based screening for gastric cancer (PBSGC) in Japan since 2015. Although non-sedative EGD (NSEGD) is recommended by the Japanese Society of Gastrointestinal Cancer screening considering the risk of adverse events caused by sedation, its tolerability is unclear. This study aims to evaluate the tolerability of NSEGD among PBSGC participants in a real-world setting.

Aims & Methods

The paper-based questionnaire survey was conducted for the PBSGC participants who received NSEGD in 16 institutions in Sinagawa-ku Tokyo Japan from April 2021 to August 2022. The questionnaire items were filled out anonymously by the participants of PBSCG soon after they have undergone NSEGD. The questionnaire items included; consented to answer this survey, age, sex, number of experienced EGD, the experience of sedation during EGD, discomfort regarding NSEGD, and willingness to take sedated EGD next time. The discomfort regarding NSEGD was evaluated by the following 4 items, A: impression of NSEGD, B: whether you can take NSEGD again, C: impression of examination time, D: feeling after taking NSEGD. They were evaluated by 6 steps face scale: 1 is the most comfortable, and 6 is the most uncomfortable. Medical staff in each institution filled out the inserting route (oral, or tans-nasal), a used endoscope (normal or thin), the presence of biopsy, and examination time.

Results

The consent to answer the questionnaire survey was obtained from 1011 out of 1063 participants. The median age was 68 years (range: 40-93). There were 434 men and 554 women (not answered=23). The number of experienced EGD was 133 participants for the first time, 672 participants for 1-5 times, and 203 participants for more than 6 times (not answered=3). Regarding the experience of sedation during EGD, 184 participants had experienced the sedated EGD, whereas 660 participants had not experienced sedated EGD (first-time examination: not answered: unknown=133:30:4).
The proportion of participants who answered 3 points or less on the discomfort scales was 68%, 81%, 85%, and 84% respectively. Regarding the willingness to take sedated EGD next time, 391 participants hoped to receive the sedated EGD next time, whereas 576 participants answered that they can take NSEGD again. Inserting route and used endoscope were as follows: transnasal route with thin scope: peroral route with thin scope: peroral route with normal scope=594:232:63(unanswered=122). A biopsy was performed with 53 participants. The examination time was as follows: less than 6min: 7min: 8min: 9min: more than 10min=176:190:146:133:129:133(unanswered=104). Of the valid response from 564 participants who received the transnasal endoscopy, 218 participants (38.7%) hoped to receive sedated endoscopy next time.

Conclusion

Real-world data from on-site questionnaire surveys for the participants who received the NSEGD as PBSGC showed that non-sedative transnasal EGD is intolerable for some participants. The support for the participants who are intolerable to continue the current NSEGD in the PBSGC program should be considered in Japan.

References

1. Hamashima C. Update version of the Japanese Guidelines for Gastric Cancer Screening. Japanese journal of clinical oncology 2018; 48: 673-683. doi:10.1093/jjco/hyy077

Disclosure

There is Nothing to disclose.

Introduction

Early gastric cancers (EGC) are confined to the gastric mucosa and submucosa irrespective of lymph node metastases. The proportion of gastric cancers diagnosed at an early stage varies considerably between Western countries but is low compared to countries with a screening program for gastric cancer. The majority of EGC patients have been treated with surgical resection including standard lymphadenectomy in Western countries. In contrast, Asian countries have treated larger proportions of EGC with endoscopic submucosal dissection (ESD) followed by estimation of risk of lymph node metastases based on histopathological characteristics. The aim of the present study was to characterize EGCs in Central Norway before ESD was an available treatment option. Furthermore, we aimed to assess histopathological characteristics associated with lymph node metastases and long-term survival in our cohort of EGC patients.

Aims & Methods

The study was a retrospective population-based study using patients identified from the Norwegian Cancer Registry and Norwegian Patient Registry (NPR). The annual number of gastroscopies was retrieved from NPR. 1205 patients were diagnosed with gastric cancer from 2001 to 2016, a period when gastrectomy with a modified D2 resection was standard treatment. In accordance with Western diagnostic criteria, patients with carcinoma in situ were not included. Patients who received neoadjuvant chemotherapy and histologically ypT0 or ypT1 were excluded to study only chemo naïve (true) EGC. Histopathological specimens were re-examined and eCura score risk stratification was calculated. Finally, long-term survival and cause of death were assessed.

Results

Of the 1205 patients with gastric cancer 88 (7.3%) had EGC. The number of gastric cancers declined (p=0.010), but the relative proportion of EGC was unchanged during the study period despite a doubling of annual gastroscopies at a national level during the study period. Patients with EGC had median age 77 (43-91) years vs. 74 (21-99) years for non-EGC controls. EGCs were more often of the Lauren intestinal type (p<0.001) and were more often localized in the antrum or corpus. Eighty-three patients underwent surgical resection and eight (9.0%) of these had N+ disease. An eCura score could be calculated for 79 EGCs. A significant proportion (9.4%, n=5) of the patients with a low risk eCura had lymph node metastases, whereas further exclusion of tumours with histological ulceration or SM2 invasion in a post-hoc analysis identified a N0 cohort (n=36). Recurrence of cancer was diagnosed in seven (8.1%) patients after a median time of 29 (14-124) months from the EGC diagnosis. Fifty-five (62.5%) EGC patients died during follow-up, whereof 43 (78.2%) deaths were unrelated to EGC, seven (12.7%) died of cancer recurrence and five (9.1%) died from postoperative complications. Median survival for EGC patients was 117.1 months (95% CI 99.8-134.3) and 5-year overall survival 75%. Approximately half of deaths related to cancer recurrence (3 of 7) occurred more than five years after the EGC diagnosis.

Conclusion

EGCs constituted a minor but constant proportion of gastric cancers despite a considerable increase in gastroscopies. In this historic cohort with formal gastric resection for EGC, 9.0% had pN+ disease. Low risk eCura score alone was insufficient to predict pN0 disease whereas additional exclusion of patients with histological ulceration or SM2 infiltration identified a pN0 cohort. Long-term follow-up of more than five years is needed to assess EGC related mortality.

Introduction

Gastric cancer remains a major global cause of cancer mortality. Early detection and accurate risk stratification are crucial for improving prognosis. Noninvasive, affordable serum tests are essential for mass screening. We compared the updated ABC method (pepsinogen I/II and gastrin-17) and a novel gastric cancer scoring system (“new scoring system”) regarding their effectiveness in screening early gastric cancer and precancerous lesions, risk stratification, and missed diagnosis prevention.

Aims & Methods

From April to November 2024, 7,304 asymptomatic individuals from Yuhang District, Hangzhou, China, participated in community-based screening. Serum pepsinogen I (PGI), PGII, PGI/II ratio (PGR), gastrin-17 (G-17), and H. pylori antibody were tested. Participants were stratified into low-, medium-, or high-risk groups using the ABC method and the new scoring system. A total of 654 medium- and high-risk participants underwent endoscopy and histopathology. Detection rates of gastric cancer, intraepithelial neoplasia, and atrophic gastritis were compared. Missed diagnosis rates in low-risk groups were analyzed assuming no endoscopy.

Results

The ABC method classified 90.55% as low-risk, 7.69% medium-risk, and 1.75% high-risk. The new scoring system classified 59.42% as low-risk, 32.67% medium-risk, and 7.91% high-risk. Endoscopy detected 11 gastric cancers (1.68%, 10 early-stage), 21 intraepithelial neoplasias (3.21%), and 98 atrophic gastritis cases (14.98%).
Gastric cancer detection rates in medium/high-risk groups were similar: ABC 1.58% (3/190), new scoring 1.77% (10/565) (p=1.000). Atrophic gastritis rates were comparable (ABC 14.21%, new scoring 15.04%, p=0.872). In the high-risk subgroup, the new scoring system detected significantly more atrophic gastritis cases (29.87% vs ABC 16.33%).
In low-risk groups, the ABC method would miss 8 of 11 gastric cancers (72.73%) without endoscopy; the new scoring system would miss only 1 case (9.09%, p=0.009). ROC analysis showed higher AUC for the new scoring system (0.60 vs 0.51). Decision curve analysis indicated superior net clinical benefit for the new scoring system at threshold probabilities above 0.2. The new scoring system showed higher sensitivity for early-stage disease detection, whereas ABC had slightly higher specificity.

Conclusion

Both systems showed similar performance in detecting gastric cancer and precancerous lesions among medium- and high-risk populations. The new scoring system significantly reduced missed diagnoses in low-risk groups and improved identification of high-risk precancerous conditions. Incorporating ROC, DCA, and accuracy metrics, the new scoring system offers enhanced flexibility for risk stratification, making it potentially more effective for population-based gastric cancer screening, especially in resource-limited settings. Further validation in larger cohorts is warranted.

Disclosure

Nothing to disclose.

Introduction

Gastric Cancer has been a heavy burden in far East Asian countries. Although there are national programs in South Korea and Japan, their evidence has been suggested as insufficient. We aimed to synthesize currently available comparative data on gastric cancer mortality in healthy, asymptomatic adults by explicitly classifying the screening effects through study designs and types of intervention effects.

Aims & Methods

We searched multiple databases through October 31, 2022, for this systematic review　and meta-analysis. Studies of any design that compared gastric cancer mortality among radiographic or endoscopic screening and no screening in a community-dwelling adult population was included. The method included a duplicate assessment of eligibility, double extraction of summary data, and validity assessment using the Risk Of Bias In Non-randomized Studies of Interventions tool. Bayesian three-level hierarchical random-effects meta-analysis synthesized data corrected for self-selection bias on the relative risk (RR) for per-protocol (PP) and intention-to-screening (ITS) effects. The study registration number at PROSPERO is CRD42021277126.

Results

We included seven studies in which a screening program was newly introduced (median attendance rate, 31%; at a moderate-to-critical risk of bias) and seven cohort and eight case-control studies with ongoing screening programs (median attendance rate, 21%; all at critical risk of bias); thus, data of 1,667,117 subjects were included. For the PP effect, the average risk reduction was significant for endoscopy (RR 0.58; 95% credible interval: 0.39–0.90) but non-significant for radiography (RR 0.80; 95%CI 0.60–1.06). The ITS effect was not significant for both radiography (0.98; 95%CI 0.86–1.21) and endoscopy (RR 0.94; 95%CI 0.74–1.44). The effects' magnitude depended on the self-selection bias correction assumptions. Restricting the scope of East Asian studies only did not change the results.

Conclusion

In limited-quality observational evidence from high-prevalence regions, screening reduced gastric cancer mortality; however, the effects diminished at a program level.

Disclosure

I have no conflict of interest.

Introduction

There is limited data on the impact of sedation on cardio-cerebrovascular disease (CCD) adverse events after esophagogastroduodenoscopy (EGD) in patients with gastric cancer. We investigated the incidence rate, risk factors and the impact of sedation on CCD adverse events after surveillance EGD in patients with gastric cancer.

Aims & Methods

We performed a nationwide population-based cohort study using Health Insurance Review and Assessment Service databases from January 1, 2018 to December 31, 2020. Using a propensity score-matched analysis, the patients with gastric cancer were divided into two groups: sedative agent users and non-users for surveillance EGD. We compared the occurrence of 14-day CCD adverse events between the two groups.

Results

Of 103,463 patients with gastric cancer, newly diagnosed CCD adverse events occurred in 2.57% within 14 days after surveillance EGD. Sedative agent was used in 41.3% during the EGD. The incidence rate of CCD adverse events with non-sedation and sedation are 315.4/10,000 and 173.6/10,000, respectively. Propensity score matching based on confounding variables yielded 56,016 matched patients (28,008 pairs). Between sedative agent users and non-users, there were not significantly difference in the occurrence of 14-day CCD adverse events, cardiac adverse events, cerebral adverse events, and other vascular adverse events, respectively. (2.28% vs. 2.22%, P = 0.69; 0.86% vs. 0.93%, P = 0.42; 1.44% vs. 1.31%, P = 0.23; 0.74% vs. 0.84%, P = 0.20).

Conclusion

In a population-based, matched cohort study, sedation during surveillance EGD was not associated with CCD adverse events in patients with gastric cancer. These findings suggest that use of sedative agent may be considered in patients with gastric cancer during surveillance EGD without excessive concerns for CCD adverse events.

Introduction

Gastric cancer (GC) incidence based on the endoscopic Kyoto classification of gastritis has not been systematically investigated using time-to-event analysis. Therefore, we examined GC incidence in an endoscopic surveillance cohort.

Aims & Methods

This study was retrospectively conducted at the Toyoshima Endoscopy Clinic. Patients who underwent two or more esophagogastroduodenoscopies (EGDs) were enrolled. GC incidence was based on Kyoto classification scores, such as atrophy, intestinal metaplasia (IM), enlarged folds (EF), nodularity, diffuse redness (DR), and total Kyoto scores. Atrophy was classified using the Kimura-Takemoto classification. Non-atrophy and Closed I, Closed II and III, and Open I to III were scored as atrophy scores of 0, 1, and 2, respectively. IM scores of 0, 1, and 2 were defined as the absence of IM, IM limited to the antrum, and IM extending into the corpus, respectively. The absence and presence of EF were scored as 0 and 1, respectively. The absence and presence of nodularity were scored 0 and 1, respectively. DR scores of 0, 1, and 2 were defined as the absence of DR, mild DR and/or DR with partial regular arrangement of collecting venules (RAC), and severe DR without RAC, respectively. The endoscopists diagnosed the Kyoto classification scores on-site during the index EGD. Hazard ratios [HRs] adjusted for age and sex were calculated using a Cox hazard model. This study was approved by the institutional review board of the Yoyogi Mental Clinic (approval no. RKK227).

Results

A total of 6718 patients were enrolled (mean age 55.0 years; men 44.2%). Of them, 3754, 2264, 700 patients were in H. pylori uninfected, eradicated, and currently infected status, respectively. Patients were followed up for up to 5.02 years. The mean Kyoto classification scores for atrophy, IM, EF, nodularity, DR, and total Kyoto were 0.585, 0.284, 0.039, 0.026, 0.312, and 1.247, respectively. During the follow-up period, 37 GCs occurred in 34 patients. All GCs were superficial and within the submucosal depth. Lauren’s intestinal type made up 89.1% of GCs. The annual incidence rates of GC were 0.04%, 0.17%, and 0.73% for atrophy scores of 0, 1, and 2; 0.07%, 0.25%, and 1.10% for IM scores of 0, 1, and 2; 0.17% and 0.92% for EF scores of 0 and 1; and 0.06%, 0.55%, and 0.74% for DR scores of 0, 1, and 2, respectively. The annual incidence rate of GC was 0.19%. The GC incidence rates were 0.05, 0.07, 0.47, and 1.27%/year for the total Kyoto scores of 0-1, 2-3, 4, and 5-8, respectively. Multivariate analysis showed that Kyoto atrophy scores 1 (HR with score 0 as reference: 3.66, 95% confidence interval [CI]: 1.06-12.61), 2 (11.60, 3.82-35.27), IM score 2 (9.92, 4.37-22.54), EF score 1 (4.03, 1.63-9.96), DR scores 1 (6.22, 2.65-14.56), and 2 (10.01, 3.73-26.86) were associated with GC incidence, whereas nodularity scores were not. The total Kyoto scores of 4 (HR with total Kyoto scores 0-1 as reference: 6.23, 95% CI: 1.93-20.13) and 5-8 (16.45, 6.29-43.03) were more likely to develop GC, whereas the total Kyoto scores 2-3 were not, as shown in table. The HR of the total Kyoto score for developing GC per 1 rank was 1.75 (95% CI: 1.46-2.09, P<0.001).

Conclusion

A high total Kyoto score (≥ 4) was associated with GC incidence. The endoscopy-based diagnosis of gastritis can stratify GC risk.

Disclosure

All authors disclosed no personal conflicts of interest.

Introduction

There is a paucity of information on the efficacy and safety of endoscopic resection (ER) of gastric submucosal tumors (SMT) in Japan where ER for early gastric cancer is extremely popular.

Aims & Methods

A multicenter retrospective study was conducted to elucidate the current situation of ER for gastric SMT in Japanese endoscopic practice. Clinicopathological data of consecutive patients with gastric SMT who underwent ER in 12 Japanese hospitals were collected from the first case until August 2020.

Results

A total of 117 patients with 118 lesions were enrolled. The number of patients with gastric SMT who underwent ER increased over the years. The mean (SD) endoscopic tumor size was 20 (7.2) mm. The growth type was primarily intraluminal (90%). 87 (74%) of the procedures were performed in an operating room under general anesthesia. The tunneling method was used in 5 (4%) cases. The mean (SD) resection and wound closure times were 58 (38) min and 31 (41) min, respectively. Complete ER was achieved for 117 (99%) lesions. Full-thickness resection rate was 44%; however, only 12 (10%) patients required abdominal paracentesis for pneumoperitoneum. Endoscopic treatments were completed in 115 (97%) lesions, while three lesions required conversions to laparoscopic surgery due to luminal collapse, uncontrolled bleeding, and difficulty in defect closure. Two cases of delayed bleeding were managed by endoscopic hemostasis, one of which required a blood transfusion. Gastrointestinal stromal tumors were the most common pathology (74%). The R0 resection rate was 76%. Survival and recurrence on August 31, 2021, were confirmed in 112 patients (96%) with a mean (SD) follow-up period of 4.3 (2.9) years. 109 (94%) were confirmed alive, the vital status of five patients was unknown, and three patients had died of other diseases. No recurrence was observed. The 5-year overall survival rate was 98.9% (95% confidence interval, 97.8−100%).

Conclusion

The performance of ER for gastric SMT is increasing in Japan. The technique seems feasible in Japanese endoscopic practice, warranting further validation in a prospective study.